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From Big Data to Big Knowledge – OptimizingMedication ManagementSession 157, March 7, 2018Dave Webster, RPh MSBA, Associate Director of Pharmacy Operations, URMC StrongMaria Schutt, EdD, Director Education & Optimization Services, BD1

Conflict of InterestDavid Webster, RPh, MSBAHas no real or apparent conflicts of interest to report.Dr. Maria Schutt, EdDHas no real or apparent conflicts of interest to report.Maria Schutt is an employee of BD2

Agenda1. Learning Objectives2. Setting the Stage: Health System Profile3. The Medication Availability Challenge4. Practice Improvement Methodology5. Inventory Optimization Analytics6. University of Rochester Medical Center Optimization Case-study7. Recommendations3

Learning Objectives Define the challenges of inventory management with a focus onreducing medication waste across a health system Utilize analytics tools, national benchmarking and machine learningalgorithms to target automatic dispensing cabinets (ADC)medication waste reduction Describe a business improvement plan to target medication wastereduction from ADCs Measure, monitor, and evaluate data to adjust program to maximizeresults Develop, define and execute a comprehensive action plan to reducemedication waste in ADCs using national benchmarking andpredictive analytical tools4

University of Rochester Medical Center (URMC)Rochester, New YorkStrong Memorial Hospital 839 beds 100% occupancy Quaternary care Level 1 trauma Pediatric hospital Oncology hospital/Infusion centers (on andoff-site) Off-site emergency services center Off-site ambulatory surgery center Off-site sterile compounding center 340B EligibleHighland Hospital 261 beds 100% occupancy Acute care Active emergency department Known for: Nationally ranked geriatrics program Orthopedic surgery Region’s leading gastric bypassprogram Comprehensive women’s services 340B (Rural Referral Center)Regional Community HospitalsAmbulatory Sites FF Thompson (125 beds) Jones Memorial Hospital (70 beds) Noyes Memorial Hospital (67 beds) Several contractual relationships with other community based5hospitals and clinics Medical clinics/primary care Specialty Pharmacy Services Contract Pharmacy Services 10 licensed ambulatory pharmacies Home Infusion Pharmacy Services

Highland PharmacyModelDecentralized Dispensing ModelCentral11% Total Doses Dispensed: 6,600 doses/day Total Doses Dispensed ADCs: 5,900 doses/dayADCs89%36 ADC units; 20 Anesthesia units Override Rate: 1.7% ADC Replenishment: Once Daily 340B Facility Cartfill for patient specific orders6

Strong PharmacyModel Total Doses Dispensed 18,000 doses/day Total Doses Dispensed ADCs: 7,900 doses/day124 ADC units; 63 Anesthesiaunits; Override Rate: 2.5%**Inpatient ED PACUs ADC Replenishment: 2-3times daily 340B Facility Cart fill for patient specificordersADCs44%7

Polling Question!How do you manage/adjust your facility’s ADC PAR levels?1.Review/adjust when prompted2.Review/adjust annually3.Review/adjust monthly4.Review/adjust daily/weekly8

Polling Question!Generally, how often do you replenish your ADCs?1.Less than once daily2.Once daily3.Twice daily4.Three times or more daily9

Pharmacy Dispensing Models:Highland and Strong Hospitals73,632,000 data messages per year forADCs10

Dispensing Data Transactions12,113,516,199 (12 billion) data messages for ADCs 2234 FacilitiesPatient encounters (1,224,139,122) (1.2 billion)11

Goal of a Medication Management System“In essence, a well-planned and implemented medication management system supports patient safety and improves thequality of care by doing the following: Reducing variation, errors, and misuseUsing evidence-based practices to develop medication management processesManaging critical processes to promote safe medication management throughout the organizationStandardizing equipment and handling processes, including those for sample medications, across the organization toimprove the medication management systemMonitoring the medication management process for efficiency, quality, and safety” - Excerpt from The Joint Commission 1How are our peersperforming?2How can we leverage datato drive action?3What is the recommendedimprovement methodology?Basis of Practice Improvement MethodologyDevice Generated DataRegulations &GuidelinesWhite PapersReview of industryguidelines and pharmacypractice regulations(JCHAO, ISMP)12Supporting evidencebased on previouspublished workStarting with KPIs that areavailable in the device today

Medication Availability ChallengeMost hospitals face these challenges leading to these problems creating a sizable impact.Medication is out of stock at themedication dispensing machineFrequent refillscreates long waittimes for nursesand extra workPicking cycle inpharmacy doesnot correspond todemand on floorsExcessive inventory is stocked inautomated dispensing cabinets toensure medication availability SLA’sInefficient workflow &productivity due tointerruptions and distractionsLow hospital staff satisfactionIncreased cost due toinefficient workflowIncreased cost due toExpired and wasted medicationand bloated inventory on hand13 2,400 hours of time each year isconsumed by nursing calls to pharmacyin a 350 bed hospital20 minutes to track down each missingmedicationPharmacy staff spends 3-4 hours/day onpurchasing, receiving and stocking medsOn average, 20% of ADC pocketshave not been accessed in 6 monthsOn average, 6-7% of pharmacy inventoryspend is wastedAn average hospital loses 150k every 3months from expired medications

Practice Improvement MethodologyPRACTICE ASSESSMENT &SUCCESS PLANEDUCATION SERVICES &CORE COMPETENCIESINTEGRATED ANALYTICS& BENCHMARKSIMPROVEMENT &ADOPTION SUPPORTSite-SpecificSuccess PlanTraining Plan, Workshops,& CertificationsPAR Optimization &Workflow AnalyticsPractice ImprovementPlatformGuiding Principles &Operational KPI’sSuccess Community &User Group AccessNational PharmacyBenchmarksOptimization SpecialistSupportEDUCATE – ADOPT - OPTIMIZE14

Utilizing Data, Analytics andBenchmarking to OptimizeGUIDING PRINCIPLES(Practice, process, feature usage)12645KEY PERFORMANCE INDICATORS(KPI)CABSYSTEM LEVEL OUTCOMES 3Defines a process, policy, or settingand the associated compliancemetrics to track performanceMeasure of the customer’sprocess, typically at a site or IDNlevelFinancial, efficiency, or patientsafety metricsExampleRefill Frequencyy f(x)KPI f(practice , processes)Discrepancy Mgmt.PAR level Mgmt.Cycle CountsStock-outPercentage15MedicationAvailability

Guiding Principles and Established KPIsKey Performance IndicatorsGuiding PrinciplesRefill FrequencyRemove - Pulling PracticeStock-out percentageNursing Inventory CountsRemove - OverrideVend-to-Refill ratioPharmacy Inventory CountsWitness OverrideBlind stock-outs per stationOutdatesTemp Patients# of pockets w/out vend greater than policy daysWitness on EmptyingReturn BinWaste WitnessDestockDiscrepancy - ResolutionStandard StockConformance to CS PolicyAverage removed outdates per stationDoses dispensed from Pyxis MedStation# of medications greater than 2 loads and unloadsRATIONALERATIONALERegulations &GuidelinesDevice Generated DataWhite Papers16

Data Science l(s)identifiedthroughtesting andevaluationIdentify topvariablesthatpredictKPIs Goal: Understand the relationship between KPIs and Guiding Principles Foundation for “smart recommendation engine”17 million dispensed doses/year Benchmarking data: 300 health systems, 330

Why Optimize?HIGHLAND STRONG ADCs integral to the dispense model; 89% of alldoses dispensed from ADCsWaste Expired Medications from ADCs Business Improvement Plan (BIP) for wastereductionPhysical constraints impose challenge ondistribution and need for efficient processes Funding FTE to oversee process Inefficiencies: Focus on Replenishment Process No pneumatic tube system Size-constricted medication rooms limit ability toadd storage capacity for medications Maximize resources involved in refill process Improve vend-to-refill ratios Maximize use of resources involved in refill process Improve vend-to-refill ratios Create process for managing changes in PAR levels Stock-outs: Rates increasing, not meeting goals Goal of eliminating predicted stock-outs Improve nursing satisfaction Improve time-to-refill (service recovery)Budgetary constraints18

Why Optimize?Medication cost volatilitycontinues to drive focuson cost reductionstrategies, includinginventory management19

Initial Challenges and Considerations Adjusting PAR levels and reports required Data integrity Cost of file integration from EMR to ADC20

Optimization Goals at HighlandAdopt guiding principles in refillprocess for ADCsVend-toRefill RatioOptimize Vend-to-Refill ratio, work toward one majordevice replenishment per dayMaintain stock-out rateStock-outRateMaintain a stock-out rate at or below one percentMaximize availability ofmedications from ADCsDispense %from ADCs21Target 90% dispenses from ADCs

Optimization Business ImprovementPlan - Highland1. Optimize Device Inventory Adjusted min/max (via report analysis) Move most-refilled medications to larger pockets in the ADC Add pockets specifically for highest-use medications2. Planning for One Refill per Day Analyze department workflow and resources3. Avoid Nurse-Tech Workflow Conflicts Identify time of most frequent vends22

Knowledge Check: True or False?Medication inventory across a health system is becoming moreimportant due to rising medication costs and health systemcomplexities.True!23

Inventory Optimization Results at HighlandSource: URMC Medication Dispensing Data: Aug 2015 –Aug 201724

Inventory Optimization Results at HighlandSource: URMC Medication Dispensing Data: Aug 2015 –Aug 201725

Inventory Optimization Results at HighlandMar 20160.8%STOCK-OUT RATEAug 2017Initial Focus:Maintain stockout rate below 1%March 201685%DISPENSE FROMADCs0.9%STOCK-OUT RATEAug 2017Initial Focus:Improve dispense%, particularly inthe ED2689%DISPENSE FROMADCs

Optimization Goals at StrongExpiringinventoryReduce expiring inventory in ADCsInventorycarrying costReduce level of inventory in ADCsStock-outReduce or maintain stock-out rateADOPT Destock feature on ESinto waste reduction processOPTIMIZE medicationavailability in ADCsDedicated resource for active inventory management Moving product from low use to high use areas with Destock feature Using reports to identify soon-to-expire medications Identify highest risk medications (short expiration date)27

28Waste Reduction Plan at StrongTotal Expired Medications 2015Goal with ReductionAnnual SavingsCostsNet SavingsIdentifyBaselineCreate GoalSource: URMC Medication Dispensing Data: Aug 2015 –Aug 201728Develop BIP 391,409.00 241,409.00 150,000.00 38,147.00 111,853.00

Waste Reduction Plan at Strong2017 represents 70% reduction in waste compared to baseline year for inpatient/ED unitsSource: URMC Medication Waste Data: January 2016 – November 201729

Inventory Optimization w/ Analytics: StrongInventory OptimizationPerform PAR level optimization to reducestock-outs and waste at least 1x quarter 3,200 recommendations for medicationlocations accepted or modified Changed PAR levels on 4,000 medications onStandard stock Leveraging usage data in chart to look overprevious 30,60, 90, 120, and 365 days Consider whether medication should be onstandard stock in the first place Realized significant inventory carrying costhiding in standard stock inventory30

Inventory Optimization Results at StrongAvg. Removed Outdates perStation43333226Vend-to-Refill RatioStock-Out 186.15.89.25.90.60%0.40%Avg. Removed Outdates perStation nearly halvedStock out rate drops by 50%Source: URMC Medication Dispensing Data: June 2015 –Aug -160.20%Vend / Refill ratio almost doubles

Inventory Optimization Results at StrongStock-Out PercentageAverage Pre-OptimizationExpired Doses per PocketAverage Post-OptimizationSum of ExpiredDoses Pre1.83Sum of ExpiredDoses Post2,4930.505351,958 fewer expired medications in samepocketsFor over 3,200 medications, stock outrate has improved 266%Source: URMC Medication Dispensing Data: June 2015 –Aug 201732